<extend name="Public:base" />


<block name="nav"></block>


<block name="main">

<div class="block">

<div class="fr mr10">
	<a href="javascript:history.back();"><i class="icon-reply"></i> 返回</a>
</div>

<div class="title">活动预约</div>

<div class="p10 lh150 tline bccc ld">

请留下您的资料方便我们的教师与您联络<br>
<br>

<form id="form" action="" method="post" class="form-horizontal">

	<div class="form-group">
		<label class="col-sm-3 control-label">日期
		<span class="red">*</span></label>
		<div class="col-sm-9">
			<label><input type="radio" name="date" checked> 2015-04-08 星期三</label><br>
			<label><input type="radio" name="date"> 2015-04-15 星期三</label><br>
			<label><input type="radio" name="date"> 2015-04-22 星期三</label><br>
			<label><input type="radio" name="date"> 2015-04-29 星期三</label><br>
			<label><input type="radio" name="date"> 2015-04-25 星期六</label><br>
		</div>
	</div>

	<div class="form-group">
		<label class="col-sm-3 control-label">姓名
		<span class="red">*</span></label>
		<div class="col-sm-9">
			<input name="id" value="李乐思" class="form-control">
		</div>
	</div>

	<div class="form-group">
		<label class="col-sm-3 control-label">年级</label>
		<div class="col-sm-9">
			<input name="id" value="初3" class="form-control">
		</div>
	</div>

	<div class="form-group">
		<label class="col-sm-3 control-label">人数</label>
		<div class="col-sm-9">
			<input name="id" value="3" class="form-control">
		</div>
	</div>

	<div class="form-group">
		<label class="col-sm-3 control-label">出生日期</label>
		<div class="col-sm-9">
			<input name="id" type="date" value="1998-12-3" class="form-control">
		</div>
	</div>

	<div class="form-group">
		<label class="col-sm-3 control-label">就读学校</label>
		<div class="col-sm-9">
			<input name="id" value="二中" class="form-control">
		</div>
	</div>

	<div class="form-group">
		<label class="col-sm-3 control-label">联系电话
		<span class="red">*</span></label>
		<div class="col-sm-9">
			<input name="id" value="18012345678" class="form-control">
		</div>
	</div>

	<div class="form-group">
		<label class="col-sm-3 control-label">留言</label>
		<div class="col-sm-9">
			<textarea name="id" class="form-control">开车过来可以吗？请告诉我准确地址</textarea>
		</div>
	</div>

	<div class="form-group">
		<div class="col-sm-offset-3 col-sm-9">

			<button class="btn btn-sm btn-primary">提交</button>

		</div>
	</div>
</form>

</div>

</div>


</block>
